National Performance Priority Area: Well-Woman Care, with an Emphasis on Minority and Low-Income Women (October 1, 2020 – September 30, 2021):
During the 2018-2019 Maternal Child Health (MCH) Needs Assessment, it was identified that women in North Dakota ages 18-44, particularly minority women and low-income women, were lacking in routine preventive health visits.
According to the 2018-2019 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) data, 33.5% of women (33.7% of White women, 47.3% of American Indian women and 48.4% of women of other races) reported having a “routine” check up in the 12 months prior to becoming pregnant. In the 12 months prior to pregnancy, 49% of North Dakota women had a regular OB/GYN appointment; 50.7% of White women, 33.9% of American Indian women and 39.7% of other women.
Additional explanation regarding trends in North Dakota data may be found in Section V. Supporting Documents, Supporting Document 2 - FFY 2021 Midterm Report Card.
To improve rates of these preventive health visits among reproductive age women, the MCH team gathered a group of stakeholders to review the strategies and activities to increase the number of women, ages 18-44, who report having a preventive health visit within the past 12 months.
In the MCH Well-Woman stakeholder meeting in 2021, the group identified three primary strategies that would be used to improve preventive care for women:
- Extending Medicaid to one year postpartum,
- Increasing depression screening and referral, and
- Implementing culturally appropriate messaging to reach women across the state.
Extending Medicaid to one year postpartum was identified as a key strategy to improve women’s preventive care. Women covered by Medicaid, especially minority women, are at higher risk for adverse outcomes of pregnancy. In the six weeks after a mother gives birth, Medicaid-eligible women can obtain valuable services related to the acute concerns of pregnancy and birth. However, six weeks of Medicaid coverage may not be long enough for these conditions to resolve, often leaving women unable to access necessary care due to lapse in coverage. The American College of Obstetricians and Gynecologists (ACOG) describes that after the initial postpartum period, women slowly transition from postpartum-related medical care to well-woman care that has a broader focus. It is during this time that women can begin getting appropriate interconception care to assure a healthy subsequent pregnancy and to address health concerns that could affect her long-term health outcomes overall. By extending Medicaid one year postpartum, we increase the potential for these women to enter their next pregnancy in a healthier state.
Nationally, a major focus of many women's health campaigns has been extending postpartum access to Medicaid. There is widespread understanding that extending Medicaid coverage is a strategic way to provide better access to preventive health care. One example is Illinois, which is advocating for an extension of Medicaid fueled in part by the absence of postpartum coverage. A recent study in Illinois demonstrated that 75% of maternal deaths were related to mental health and most deaths occurred within six months after giving birth. These findings highlight the need for continuity of care for women continuing for months, not mere weeks postpartum. The need for the extension of Medicaid may be particularly important for minority women: research shows that women of color and who have lower incomes are more likely to suffer from post-partum depression, which may require longer-term care and treatment.
The 2021 annual plan included two activities for expanding Medicaid to one year postpartum:
1. Convene a task force quarterly with at least three partners from the Well Woman Strategy team and North Dakota Medicaid office.
2. Identify at least three other states' strategies for extending Medicaid, including legislative foundation.
In early 2021, the MCH Women’s/Maternal Health Team did extensive research on strategies used in other states to extend Medicaid, including legislative foundation. They met with multiple nationally recognized experts regarding Medicaid policy and postpartum coverage to receive feedback, suggestions and support. The team developed several guiding documents which included an extensive review paper of strategies used in other states, potential challenges, and benefits of extending Medicaid, and policy options in North Dakota.
In June 2021, the MCH Women’s/Maternal Health Team convened a task force that included stakeholders from across North Dakota. Participants included the North Dakota Medicaid Director, Executive Director of the North Dakota Medical Association, Health Service Coordinator Medical Officer, and others. All in attendance were in favor of submitting a State Plan Amendment to cover post-partum women for up to 12 months after delivery, as current coverage lasts only 60 days after delivery. The task force recognized that there is strong national movement to extend coverage to one year after birth and the opportunity that the American Rescue Plan Act (ARPA) of 2021 provides to extend Medicaid. The North Dakota Medicaid Director agreed to develop a plan to extend Medicaid and to keep the MCH Women’s/Maternal Health Team and task force updated.
This data demonstrates that depression is a significant issue both before and after pregnancy and highlights that mental health should be at the forefront of preventive care efforts. Early identification and treatment of depression in women of childbearing years is one key component to improving the over-all health and well-being of women (and their children) in the state.
The 2021 annual plan included two activities to address depression screening:
1. By September 2021, increase the number of women who are referred after a positive PHQ-2 or PHQ-9 during their visit at a Title X clinic.
2. Identify one to three pediatric providers to pilot screening women for depression at the two-week well baby check-up.
The number of unduplicated women served in Title X clinics across North Dakota from October 2020 through September 2021 was 3,860. Of those, 3,576 received an initial depression screening utilizing the Patient Health Questionnaire – 2 (PHQ-2) and 251 received an additional screening, the PHQ-9. Results of both of these screenings led to the following: 104 referred to a private counselor, 1 taken to the hospital, 23 referred to a Human Services Center, 2 referred to the National Lifeline, and 111 counseled by the provider.
The MCH Women’s/Maternal Health Team identified three specific goals regarding depression screening at two-week well baby check-ups. First, all pediatric clinical settings should have screening post-partum for the mother at the two-week well-child visit. Second, a referral process be identified at each facility. Third, that standards for recognition and response would be identified.
To begin work on these goals, the MCH Women’s/Maternal Health team surveyed pediatricians across the state. The survey helped identify that depression screenings were taking place at some facilities during the two-week well-child and many facilities were using Edinburgh Postnatal Depression Scale. Armed with this knowledge, the team reached out to a pediatrician at Altru Health System in Grand Forks, and their clinic committed to piloting depression screening among women at the two-week well baby check-up.
The start date for piloting was January 2021, but multiple barriers prevented an on-time start. First, the administration did not agree to use the Edinburg; they chose to use the Patient Health Questionnaire (PHQ-2), with positive screens followed by the PHQ-9, as the PHQ-2/9 is used across the health system. They also felt this would be easier to enter the electronic flowsheets. They began with one pediatrician, to determine if the workflow would be interrupted. They considered asking mothers to complete the PHQ-2 pre-visit by paper, then entering the paper copy into a flowsheet in the mother’s chart. By August 2021, three pediatric providers had successfully implemented the PHQ-2 and PHQ-9 for all postpartum mothers at the two-week well-child visit and did not find any challenges with the workflow. Additional pediatric providers will begin to use this strategy in the coming year.
The MCH Women’s/Maternal Health team’s goal during the five-year plan is to increase the number of pediatric clinics across the state that are consistently screening women for depression at these routine visits for their children. Data gathered in year one provides an excellent opportunity for quality improvement in the additional years of the plan. The 2021 data suggests that adopting a specific screening tool statewide for consistency may be unrealistic. The piloting site determined that the PHQ2/9 were the best fit at their facility to assess postpartum depression. The pilot site found that at their facility, there was no significant change in workflow when the screening was adopted.
In year two, the MCH Women’s/Maternal Health team will work with the pilot site to determine if it would be appropriate for them to share their successes and challenges with a wider audience of pediatricians. The team may be able to leverage this site’s knowledge and successes to encourage a larger number of pediatricians to adopt screening statewide. Further, conversations with the President of the American Academy of Pediatrics (AAP) in North Dakota identified that the AAP and the president herself strongly support the use of postpartum screening at well-child visits.
Given the success of strategy one, expanding Medicaid coverage until one year postpartum, the team expects the impact of screening of women for postpartum depression will be amplified in future years. Screening for postpartum depression is only effective if appropriate referrals are made and if the woman can follow-up on the referral provided. Expanding Medicaid coverage until one-year post-partum is one step towards ensuring that if a woman would like to seek mental health, she has the insurance coverage to do so.
The third strategy the MCH Women’s/Maternal Health team identified was implementing a media campaign that would incorporate culturally-specific language to promote preventive care. The activities that were planned in the 2020-21 year included:
1. Holding a training on participatory grant making strategy for partners to develop media campaign tailored to their communities, ensuring all strategies use the scientifically rigorous strategies for well woman care: tailored messaging, interactive social media, and culturally-specific media channels.
2. Convening three additional quarterly meeting with grantees to implement campaigns.
3. Disseminating campaigns to the public for viewing.
The MCH Women’s/Maternal Health team recruited eight partners who serve minority and low-income women across various locations in the state to improve messaging for their communities using culturally appropriate campaigns. To ensure an equitable approach to funding decisions, ‘participatory grant making’ was utilized to determine allocation of funding. In one type of participatory grant making process, partners share proposals with each other, then meet in person to discuss their proposals. Each organization has funding to ‘gift’ to other organizations.
In early 2021, MCH partners joined by the Microsoft Teams platform for a half-day session to share project ideas and determine funding allocations. A nationally recognized participatory grant making facilitator guided participants in the session. All groups had seven minutes to ‘pitch’ their idea to each other. Time was provided for each organization to determine a funding amount to allocate to other groups. After the session, contracts for the participating organizations were executed by North Dakota Department of Health (NDDoH). Regular opportunities for collaboration and sharing were provided throughout the year. The goal was to provide three stakeholder meetings but given most contracts were not executed until June 2021, and projects did not begin until late summer/early fall, only one additional stakeholder meeting was held.
Grantees, a summary of their project, and the goals achieved in 2021 are listed below. Some of the grantees have completed their work as of September 2021. Others are continuing their work, through additional funding that was provided by the Women’s Way initiative.
South Sudanese Foundation
- The South Sudanese Foundation is a nonprofit organization in Fargo focusing on serving a range of needs among African immigrants. In 2021, the South Sudanese Foundation developed and executed a radio campaign aimed at reaching African women and increasing preventive health visits. Twenty-four programs were aired in their native language which had a statewide reach and large listener base.
Jamestown Regional – No Excuses Program:
- Jamestown Regional Medical Center is a hospital in Jamestown which offers a specialized program called No Excuses, aimed at providing access to healthcare for all. The project was expanded through MCH funding to specifically focus more on well-woman services. The goals of the project were outreach activities to reach underserved populations in the Jamestown area and educate them about this program.
Motherland Health
- Motherland Health is a mental health organization focused on immigrants in Fargo. Their project targeted underserved women who were receiving mental health services and providing education on well-woman preventive health care.
Women Empowerment Outreach (WEO)
- Women Empowerment Outreach is a new nonprofit organization located in Williston. WEO hosted a conference called ‘Discovering the Devine Woman Within’ on June 25 and 26, 2021, which targeted low-income minority women. The conference partnered with the local Public Health Department in Williston, and offered topics such as Women’s Health, Tobacco Cessation, and COVID vaccination. Invited speakers discussed spirituality and the importance of women taking care of their physical health.
Sacred Pipe – Modern Moccasins:
- This nonprofit organization serves the urban indigenous community in the Bismarck/Mandan area. They implemented a series called ‘Reclaiming Our Community’, which was a three-part mini-series. “Reclaiming Our Community: New Life” was held April 23-24, 2021, in Bismarck. It featured three prominent speakers in the community: Melanie Stoneman, Pearl Walker Swaney, and Jayne Young Bear. Each speaker discussed topics of women’s traditional birthing practices, traditional pre-natal and post-partum care, and parenting/preparation for new life. The second event planned was geared toward teens and featured a lock-in, however, the event was cancelled due to lack of participants. “Reclaiming Our Community: Big Aunty Energy” event was held September 9-10, 2021, in Bismarck. The event featured three speakers – Kelsey Peltier, Natasha Gourd, and Chelsea Luger. Each speaker discussed topics of women’s wellness, traditional concepts of “self-care”, and maintaining health throughout the life cycle, as well as their personal journey to understanding women’s wellness.
United African Community – Take Care of Yourself:
- The United African Community is a nonprofit organization in Grand Forks working to address a range of needs among African immigrants. They held four webinars and addressed these topics: cervical cancer screening, diabetes, nutrition, and breast cancer screening. The webinars were targeted to Liberian and Cameroonian communities in Grand Forks and members of Women of Love, an African-immigrant oriented nonprofit. The project included a bi-weekly in person exercise program for African women.
Women Empowering Women:
- This nonprofit organization in Minot organized a Health Fair, which engaged women in the Hispanic communities in western North Dakota with the medical community. Women were encouraged to establish relationships with various providers and seek out preventive health services. The event was highly successful and had local press coverage. The needs of women were assessed, and mammography and cervical screening were identified as a primary need. Women Empowering Women is currently working on a 2021-22 MCH grant application to address these needs in the next year.
Bismarck Global Neighbors
- Bismarck Global Neighbors (BGN) is a nonprofit organization in Bismarck that serves a range of needs among immigrants in the area. Bismarck Global neighbors hosted a Women’s Wellness training on August 17 and 20, 2021 in partnership with Sources of Strength. Over 10 immigrant leaders from Hispanic and African backgrounds participated in the training; this training prepared them to educate other immigrants. To educate others, they will host educational opportunities for other immigrants in their peer groups. One of the participants included an English Language Learning (ELL) teacher from Argentina from the Adult Learning Center (ALC) that partnered in providing additional trainings at the ALC in Bismarck to all the ELL teachers to implement wellness initiatives and Sources of Strength model within their classroom curriculums. In the 2021-2022 year, BGN will establish “wellness groups” within the communities of women identified in need, train peer mentors, provide transportation to/from appointments/childcare if needed.
The MCH Women’s/Maternal Health team had planned to provide the media campaigns to the public for viewing, however, most groups did not develop a broad media campaign aimed for larger audiences and public consumption, so this activity was not executed in the 2020-2021 year. For example, a broad media campaign may have been a billboard targeting African American women promoting preventive health care generally. Instead, all groups targeted a very specific population, and provided tailored, time-limited messages for specific community groups, such as providing a webinar on a specific topic, tailored to African American women, or providing seminars/workshops on a specific preventive health topic, attended by American Indian women.
A challenge faced during this reporting period was contract management and working with new grantees who had limited capacity and little experience with grants. Many hours to support each grantee was required to ensure each project’s success. To address this in 2021-22, the MCH Women’s/Maternal Health team has developed new processes for working with grantees, including one-on-one orientation sessions with each grantee prior to executing a contract, tracking sheets that are accessible for new or inexperienced grantees, and orientation documents aimed for those with little experience with grant language. The team put a great deal of effort into developing partner-friendly materials and processes for the 2021-22 year and are hopeful that the challenges faced in year one will be resolved moving forward.
An additional challenge was the limitations of the Microsoft Teams-based participatory grant making session. Grantees were not easily able to connect with one another, discuss projects, or develop relationships via this platform. Further, given the session took place online and attention spans can be limited online, the session was scheduled for less time than it should have been. In year two, the MCH Women’s/Maternal Health team plans to do an in-person, all day participatory grant making session to allow appropriate social interaction, sharing, and relationship-development across grantees.
An unexpected success of this project was the opportunity to develop an abstract for the 2022 Association of Maternal and Child Health Programs (AMCHP) conference. Multiple partners participating in this project joined together to co-author an abstract for submission. If the abstract is accepted, partners will provide a panel at the AMCHP conference, highlighting the benefits and challenges of Participatory Grant Making.
Though it was not part of the initial 2020-21 plan, the team had an opportunity to develop a health care- focused quality improvement training to improve health equity knowledge among health care facilities in North Dakota. The Sacred Pipe Resource Center was an important partner in this project, hiring a health equity training coordinator to begin the development of the health equity training. Focus groups, interviews, and community activities were completed to identify key areas of need in equity among populations in North Dakota. Areas such as communication with patients at the healthcare facility were identified as key components to be addressed in a health equity training program.
In fall 2021, North Dakota State University hired the Health Equity Coordinator, a medical doctor from Ghana in the master’s in public health program. Dr. Antwi continued to build the health equity initiative, identifying appropriate models of health equity process change that could be adopted and followed to ensure the health equity training addressed key areas of process change. Further, Dr. Antwi began working with the North and South Dakota Perinatal Quality Collaborative (NSDPQC), as the health equity training would be disseminated through NSDPQC channels. The training will be launched in late spring 2022 and will be a component of a larger health equity initiative, which will provide levels of certification to health facilities as they complete progressively more intense and comprehensive health equity trainings.
The NSDPQC has been an important partner for the NSDPQC, to reach women across the state and ensure communication with a range of providers and health facilities. The MCH Women’s/Maternal Health team has served as leadership in the NSDPQC, developing relationships with providers and facilities serving women statewide. The role has expanded to include other opportunities to work with partners in women’s health, such as a role on the Maternal Mortality Review Committee (MMRC). The MCH Women’s/Maternal Health team conducts quarterly meetings with maternal health leaders to discuss progress, partnership opportunities and current priorities. The meetings include the president of the North Dakota chapter of the American College of Obstetricians and Gynecologists (ACOG), the North Dakota president of the North Dakota Society of Obstetrics and Gynecology, and one of the three Maternal Fetal Medicine providers in North Dakota.
Finally, the MCH Women’s/Maternal Health team had the opportunity to connect with a range of programs reaching women in their homes, by connecting with doulas and home visiting programs across the state during the 2020-21 year. The team met with Nurse Family Partnership and various indigenous home visiting programs and community health workers to identify appropriate partnership opportunities. Several of these programs will apply for grants with the MCH team in 2021-2022. In addition, the team was part of initial conversations to identify whether NDDoH would be an appropriate lead partner for developing a state-wide birthing collective. In late 2021, it was determined NDDoH should continue as a partner, but not as a lead, on this exciting initiative. Further conversations are planned in 2022 to expand the birth collective, with NDDoH as an active member of the initiative.
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